Tucker's Reviews > Addiction: A Disorder of Choice

Addiction by Gene M. Heyman
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"We typically do not advocate incarceration and medical care for the same activities," Heyman observes (p. 1), yet this contradiction is manifest in the very existence of the U.S. Dept. of Justice's Drug Enforcement Agency alongside the U.S. National Institutes of Health's National Institute on Drug Abuse. He traces this ambivalence in the United States back to the early twentieth-century trends of opium eating, which was popular amongst the upper economic classes and was treated by doctors, and opium smoking, which was popular amongst the lower economic classes who tended to interact with police for reasons other than drug use. "These distinctions were institutionalized in the Harrison [Narcotics Tax] Act of of 1914," he says (p. 8).

If our criminal/medical framing of addiction is correct, then why, he questions, haven't we made more progress in fighting it using law enforcement and medicine? On the other hand, if other frameworks are correct, we would expect approaches related to those other frameworks to be more successful. For example, if drug use is a self-destructive choice (as Heyman believes), we'd expect to see success from programs that teach people to make better choices (as, he says, we do -- see p. 20).

He uses the DSM's definition of addiction. (pp. 27-28) He says the DSM only considers drugs and gambling as the instigators of addiction (as opposed to something like video games) because "[d]rugs are more likely than any other substance or activity to produce behaviorally toxic effects, to function as specious rewards, to not inhibit their own consumption, and to derail global cost-benefit analysis." (p. 150)

Researchers often describe addiction as a "chronic, relapsing disease," meaning addicts try to quit but fail. (p. 56) However, arriving at this conclusion by studying patients in clinics is wrong-headed because these people "are by definition not representative: they were in treatment." (p. 67) The author instead studied addicts' autobiographical statements and concluded that most addicts quit by age 30 -- and did so without a clinic -- in large part because of the pressures and responsibilities of adulthood. (p. 64, 70, 84) Simply as a matter of probability, he suggests that quitting drugs over the age of 30 should be thought of as "resolution" rather than "remission" of the addiction. (p. 77)

Economics and behaviorism aren't very good at accounting for self-destructive behavior. (p. 134) Many people from "seventeenth-century preachers" to "twenty-first-century addiction scientists" claim that people always choose what is in their own best interest and if they do otherwise then it probably wasn't a free choice. Yet poets since Homer have always known otherwise; artists show people "knowingly, willingly, and persistently pursuing self-destructive ends." (pp. 101-102). The author argues that "medical evidence did not turn alcoholism into a disease, but rather the assumption that voluntary behavior is not self-destructive turned alcoholism into a disease." (p. 99)

The concept of self-interest must be broken down into short-term and long-term interest. To an addict, drug use seems attractive in the moment. To steer the addict away from drugs, one must generally make the drug seem less attractive in the short-term or else persuade the addict to take a long-range view and delay gratification in favor of other activities that will be more rewarding later on. (p. 124) In defending the choice to use drugs, the addict may try to argue away the idea of long-term interest, saying that this is a "special occasion" or the "last time." As Heyman explains, "The global perspective requires a continuing sequence of choices. When there is just one choice, only the local perspective applies. When a meteor is heading for Earth, it is okay to eat cheesecake." (p. 132) Clearly this is a fallacy. If I may insert my own comment, practically speaking, when someone is considering drug use, it's not a special occasion and it's never the last time. Unfortunately, Heyman says, "a person who never chose to be an addict ends up an addict" (p. 133) because of repeated choices to use drugs 'just this one last time.' Because of this effect, people tend to make better long-term choices when they're presented with sets of choices rather than atomistic choices. (p. 137) When the choice to use drugs is considered as part of a set of other choices, like keeping one's job and family, it's harder to justify the short-term gratification. We spontaneously design such sets of choices when we plan, for example, a diet, but it's difficult and it "takes imagination and forethought." (p. 139) So, rather than calculating the long-term self-interest value for each choice, we can simplify it by following rules (such as only eating chocolate once a week and never using drugs). (pp. 161-2)

We tend to classify things as diseases as we learn more about them, because learning more about how things operate makes us feel less in control of them and makes them seem involuntary. Voluntary behavior, or behavior considered to be in the moral sphere, is defined as "behavior that is not understood". (pp. 108-109) That's the wrong way to go about deciding what's voluntary, according to Heyman. How do we really find out if a behavior is voluntary? Typically, we examine the person's behavior, rather than examining their brain. (pp. 97-98) We investigate whether the behavior can be influenced by "costs, benefits, the opinions of others, culture values, and the myriad of other factors that influence decisions." (pp. 103-104) In the case of addiction, he says it is, since many addicts quit using drugs when there are sufficient social pressures.

Drug use can alter a user's brain, but that doesn't mean the user no longer has a choice in how to deal with those changes. The user can learn to manage his or her cravings for the drug. (p. 97) When s/he does not, it simply means s/he is voluntarily choosing something self-destructive. People voluntarily do self-destructive things all the time. That in itself doesn't mean their behavior is a symptom of a mental or physical illness. (p. 87)
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October 1, 2009 – Finished Reading
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